Childhood acute respiratory infections (ARIs) are one of the most common reasons for primary care consultations and for receiving an antibiotic. Public awareness of antibiotic benefit and harms for these conditions is low. To facilitate informed decision making, ideally in collaboration with their doctor, parents need clear communication about benefits and harms. Decision aids may be able to facilitate this process.
The aim of this study was to evaluate the effectiveness of three decision aids about antibiotic use for common ARIs in children.
Adult parents of children aged 1–16 years (n = 120) were recruited from community settings and then randomised using a computer-generated randomisation sequence to receive a decision aid (n = 60) or fact sheet (n = 60). Allocation was concealed and used sealed and opaque sequentially numbered envelopes. Participants self-completed questionnaires at baseline and immediately post-intervention. The primary outcome was informed choice (conceptual and numerical knowledge; attitudes towards, and intention to use, antibiotics for a future ARI). Secondary outcomes were decisional conflict, decisional self-efficacy, and material acceptability.
After reading the information, significantly more intervention group participants made an informed choice [57%] compared with control group participants [29%] [difference 28, 95% confidence interval (CI) 11–45%, p < 0.01], and had higher total knowledge [mean difference (MD) 2.8, 95% CI 2.2–3.5, p < 0.01], conceptual knowledge (MD 0.7, 95% CI 0.4–1.1, p < 0.01) and numerical knowledge (MD 2.1, 95% CI 1.6–2.5, p < 0.01). Between-group differences in attitudes or intention to use antibiotics were not significant. Most intervention group participants found the information understandable and liked the aids’ format and features.
The decision aids prepared parents to make an informed choice about antibiotic use more than fact sheets, in a hypothetical situation. Their effect within a consultation needs to be evaluated.
Clinical Trials Registration Number: ACTRN12615000843550.
This is a preview of subscription content, log in to check access.
Buy single article
Instant access to the full article PDF.
Price includes VAT for USA
Biezen R, Pollack AJ, Harrison C, Brijnath B, Grando D, Britt HC, et al. Respiratory tract infections among children younger than 5 years: current management in Australian general practice. Med J Aust. 2015;202(5):262–5.
Hersh AL, Shapiro DJ, Pavia AT, Shah SS. Antibiotic prescribing in ambulatory pediatrics in the United States. Pediatrics. 2011;128(6):1053–61.
Meropol SB, Chen Z, Metlay JP. Reduced antibiotic prescribing for acute respiratory infections in adults and children. Br J Gen Pract. 2009;59(567):e321–8.
Grijalva CG, Nuorti JP, Griffin MR. Antibiotic prescription rates for acute respiratory tract infections in US ambulatory settings. JAMA. 2009;302(7):758–66.
Rossignoli A, Clavenna A, Bonati M. Antibiotic prescription and prevalence rate in the outpatient paediatric population: analysis of surveys published during 2000–2005. Eur J Clin Pharmacol. 2007;63(12):1099–106.
Coco AS, Horst MA, Gambler AS. Trends in broad-spectrum antibiotic prescribing for children with acute otitis media in the United States, 1998–2004. BMC Pediatr. 2009;9:41.
Venekamp RP, Sanders SL, Glasziou PP, Del Mar CB, Rovers MM. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev. 2015;(6):CD000219. doi:10.1002/14651858.CD000219.pub4.
Smith SM, Fahey T, Smucny J, Becker LA. Antibiotics for acute bronchitis. Cochrane Database Syst Rev. 2014;(3):CD000245. doi:10.1002/14651858.CD000245.pub3.
Spinks A, Glasziou PP, Del Mar CB. Antibiotics for sore throat. Cochrane Database Syst Rev. 2013;(11):CD000023. doi:10.1002/14651858.CD000023.pub4.
Gillies M, Ranakusuma A, Hoffmann T, Thorning S, McGuire T, Glasziou P, et al. Common harms from amoxicillin: a systematic review and meta-analysis of randomized placebo-controlled trials for any indication. Can Med Assoc J. 2015;187(1):E21–31.
Chung A, Perera R, Brueggemann AB, Elamin AE, Harnden A, Mayon-White R, et al. Effect of antibiotic prescribing on antibiotic resistance in individual children in primary care: prospective cohort study. Br Med J. 2007;335(7617):429.
World Health Organization. The evolving threat of antimicrobial resistance: options for action. 2012. http://whqlibdoc.who.int/publications/2012/9789241503181_eng.pdf. Accessed 11 Jan 2015.
Center for Disease Dynamics, Economics & Policy. The state of the world’s antibiotics, 2015. Washington, DC: Center for Disease Dynamics, Economics & Policy; 2015.
Cabral C, Lucas PJ, Ingram J, Hay AD, Horwood J. “It’s safer to…” parent consulting and clinician antibiotic prescribing decisions for children with respiratory tract infections: an analysis across four qualitative studies. Soc Sci Med. 2015;136–137:156–64.
Lucas PJ, Cabral C, Hay AD, Horwood J. A systematic review of parent and clinician views and perceptions that influence prescribing decisions in relation to acute childhood infections in primary care. Scand J Prim Health Care. 2015;33(1):11–20.
Hoffmann TC, Del Mar C. Patients’ expectations of the benefits and harms of treatments, screening, and tests: a systematic review. JAMA Int Med. 2015;175(2):274–86.
McNulty CA, Nichols T, French DP, Joshi P, Butler CC. Expectations for consultations and antibiotics for respiratory tract infection in primary care: the RTI clinical iceberg. Br J Gen Pract. 2013;63(612):e429–36.
Coxeter P, Del Mar C, Hoffmann T. Parents' expectations and experiences of antibiotics for acute respiratory infections in primary care. Ann Fam Med. 2017;15(2). doi:10.1370/afm.2040.
Scott JG, Cohen D, DiCicco-Bloom B, Orzano AJ, Jaen CR, Crabtree BF. Antibiotic use in acute respiratory infections and the ways patients pressure physicians for a prescription. J Fam Pract. 2001;50(10):853–8.
Butler CC, Rollnick S, Kinnersley P, Jones A, Stott N. Reducing antibiotics for respiratory tract symptoms in primary care: consolidating ‘why’ and considering ‘how’. Br J Gen Pract. 1998;48(437):1865–70.
Little P, Gould C, Williamson I, Warner G, Gantley M, Kinmonth AL. Reattendance and complications in a randomised trial of prescribing strategies for sore throat: the medicalising effect of prescribing antibiotics. Br Med J. 1997;315(7104):350–2.
Butler CC, Kinnersley P, Prout H, Rollnick S, Edwards A, Elwyn G. Antibiotics and shared decision-making in primary care. J Antimicrob Chemother. 2001;48(3):435–40.
Hoffmann TC, Montori VM, Del Mar C. The connection between evidence-based medicine and shared decision making. JAMA. 2014;312(13):1295–6.
Stacey D, Legare F, Col NF, Bennett CL, Barry MJ, Eden KB, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2014;(1):CD001431. doi:10.1002/14651858.CD001431.pub4.
Coxeter P, Del Mar CB, McGregor L, Beller EM, Hoffmann TC. Interventions to facilitate shared decision making to address antibiotic use for acute respiratory infections in primary care. Cochrane Database Syst Rev. 2015;(11):CD010907. doi:10.1002/14651858.CD010907.pub2.
Legare F, Labrecque M, LeBlanc A, Njoya M, Laurier C, Cote L, et al. Training family physicians in shared decision making for the use of antibiotics for acute respiratory infections: a pilot clustered randomized controlled trial. Health Expect. 2011;14:96–110.
Legare F, Labrecque M, Cauchon M, Castel J, Turcotte S, Grimshaw J. Training family physicians in shared decision-making to reduce the overuse of antibiotics in acute respiratory infections: a cluster randomized trial. Can Med Assoc J. 2012;184(13):E726–34.
Couet N, Labrecque M, Robitaille H, Turcotte S, Legare F. The impact of DECISION+2 on patient intention to engage in shared decision making: secondary analysis of a multicentre clustered randomized trial. Health Expect. 2015;18(6):2629–37.
Coulter A, Stilwell D, Kryworuchko J, Mullen PD, Ng CJ, van der Weijden T. A systematic development process for patient decision aids. BMC Med Inform Decis. 2013;13(Suppl 2):S2.
Cabral C, Horwood J, Hay AD, Lucas PJ. How communication affects prescription decisions in consultations for acute illness in children: a systematic review and meta-ethnography. BMC Fam Pract. 2014;15:63.
Hansen MP, Howlett J, Del Mar C, Hoffmann TC. Parents’ beliefs and knowledge about the management of acute otitis media: a qualitative study. BMC Fam Pract. 2015;16:82.
Cabral C, Ingram J, Hay AD, Horwood J. “They just say everything’s a virus”: parent’s judgment of the credibility of clinician communication in primary care consultations for respiratory tract infections in children: a qualitative study. Patient Educ Couns. 2014;95(2):248–53.
Salazar ML, English TM, Eiland LS. Caregivers’ baseline understanding and expectations of antibiotic use for their children. Clin Pediatr. 2012;51(7):632–7.
Trevena LJ, Zikmund-Fisher BJ, Edwards A, Gaissmaier W, Galesic M, Han PK, et al. Presenting quantitative information about decision outcomes: a risk communication primer for patient decision aid developers. BMC Med Inform Decis. 2013;13(Suppl 2):S7.
Carling CL, Kristoffersen DT, Flottorp S, Fretheim A, Oxman AD, Schunemann HJ, et al. The effect of alternative graphical displays used to present the benefits of antibiotics for sore throat on decisions about whether to seek treatment: a randomized trial. PLoS Med. 2009;6(8):e1000140.
NPS MedicineWise. My child has a middle ear infeciton: is an antibiotic necessary? 2015. http://www.nps.org.au/__data/assets/pdf_file/0006/72159/My-child-has-a-middle-ear-infection-is-an-antibiotic-necessary.pdf. Accessed 15 Jun 2015.
NPS MedicineWise. Sore throat. 2015. http://www.nps.org.au/conditions/ear-nose-mouth-and-throat-disorders/ear-nose-and-throat-infections/sore-throat. Accessed 15 Jun 2015.
NPS MedicineWise. Bronchitis. 2015. http://www.nps.org.au/conditions/respiratory-problems/respiratory-tract-infections/for-individuals/conditions/bronchitis. Accessed 15 Jun 2015.
Marteau TM, Dormandy E, Michie S. A measure of informed choice. Health Expect. 2001;4(2):99–108.
Hersch J, Barratt A, Jansen J, Irwig L, McGeechan K, Jacklyn G, et al. Use of a decision aid including information on overdetection to support informed choice about breast cancer screening: a randomised controlled trial. Lancet. 2015;385(9978):1642–52.
Smith SK, Trevena L, Simpson JM, Barratt A, Nutbeam D, McCaffery KJ. A decision aid to support informed choices about bowel cancer screening among adults with low education: randomised controlled trial. Br Med J. 2010;341:c5370.
Sepucha KR, Borkhoff CM, Lally J, Levin CA, Matlock DD, Ng CJ, et al. Establishing the effectiveness of patient decision aids: key constructs and measurement instruments. BMC Med Inform Decis. 2013;13(Suppl 2):S12.
Smith SK, Barratt A, Trevena L, Simpson JM, Jansen J, McCaffery KJ. A theoretical framework for measuring knowledge in screening decision aid trials. Patient Educ Couns. 2012;89(2):330–6.
Dormandy E, Michie S, Hooper R, Marteau TM. Informed choice in antenatal Down syndrome screening: a cluster-randomised trial of combined versus separate visit testing. Patient Educ Couns. 2006;61(1):56–64.
O’Connor AM. User Manual—Decisional Conflict Scale (10 item question format). Ottawa, ON: Ottawa Hospital Research Institute, 1993 (updated 2010). 2010. https://decisionaid.ohri.ca/docs/develop/User_Manuals/UM_Decisional_Conflict.pdf. Accessed 5 May 2015.
O’Connor AM. User Manual—Decision Self-Efficacy Scale. Ottawa, ON: Ottawa Hospital Research Institute, 1995 (updated 2002). 2015. https://decisionaid.ohri.ca/docs/develop/user_manuals/UM_decision_selfefficacy.pdf. Accessed 5 May 2015.
Santesso N, Rader T, Nilsen ES, Glenton C, Rosenbaum S, Ciapponi A, et al. A summary to communicate evidence from systematic reviews to the public improved understanding and accessibility of information: a randomized controlled trial. J Clin Epidemiol. 2015;68(2):182–90.
Schwartz LM, Woloshin S, Welch HG. Using a drug facts box to communicate drug benefits and harms: two randomized trials. Ann Intern Med. 2009;150(8):516–27.
McCullough AR, Rathbone J, Parekh S, Hoffmann TC, Del Mar CB. Not in my backyard: a systematic review of clinicians’ knowledge and beliefs about antibiotic resistance. J Antimicrob Chemoth. 2015;70(9):2465–73.
Grossman Z, del Torso S, Hadjipanayis A, van Esso D, Drabik A, Sharland M. Antibiotic prescribing for upper respiratory infections: European primary paediatricians’ knowledge, attitudes and practice. Acta Paediatr. 2012;101(9):935–40.
Abhyankar P, Volk RJ, Blumenthal-Barby J, Bravo P, Buchholz A, Ozanne E, et al. Balancing the presentation of information and options in patient decision aids: an updated review. BMC Med Inform Decis. 2013;13(Suppl 2):S6.
Chewning B, Bylund CL, Shah B, Arora NK, Gueguen JA, Makoul G. Patient preferences for shared decisions: a systematic review. Patient Educ Couns. 2012;86(1):9–18.
Kiesler DJ, Auerbach SM. Optimal matches of patient preferences for information, decision-making and interpersonal behavior: evidence, models and interventions. Patient Educ Couns. 2006;61(3):319–41.
Coulter A, Jenkinson C. European patients’ views on the responsiveness of health systems and healthcare providers. Eur J Public Health. 2005;15(4):355–60.
Thompson-Leduc P, Turcotte S, Labrecque M, Legare F. Prevalence of clinically significant decisional conflict: an analysis of five studies on decision-making in primary care. Br Med J Open. 2016;6(6):e011490.
Gruber C, Keil T, Kulig M, Roll S, Wahn U, Wahn V. History of respiratory infections in the first 12 yr among children from a birth cohort. Pediatr Allergy Immunol. 2008;19(6):505–12.
Adab P, Marshall T, Rouse A, Randhawa B, Sangha H, Bhangoo N. Randomised controlled trial of the effect of evidence based information on women’s willingness to participate in cervical cancer screening. J Epidemiol Community Health. 2003;57(8):589–93.
Kellar I, Sutton S, Griffin S, Prevost AT, Kinmonth AL, Marteau TM. Evaluation of an informed choice invitation for type 2 diabetes screening. Patient Educ Couns. 2008;72(2):232–8.
The authors thank Bridget Abell, Sharon Sanders, and Laura Bergade for assistance with recruitment and survey administration, and Elaine Beller for statistical advice.
All authors contributed to the study design and data interpretation. Tammy Hoffman conceptualised the decision aids, and Peter Coxeter, Tammy Hoffman and Chris Del Mar developed the decision aids and designed the trial protocol. Peter Coxeter led the administration of the trial and statistical analysis, and wrote the first draft of the article. All authors contributed to subsequent drafts and the final version.
This study was approved by the Bond University Human Research Ethics Committee and was conducted in accordance with the ethical standards of the Declaration of Helsinki. Informed consent was obtained from all participants prior to study enrolment.
Conflict of interest
Peter Coxeter, Chris Del Mar and Tammy Hoffman declare no competing interests.
The National Health and Medical Research Council funded the study (APP1044904), and the Australian Commission on Safety and Quality in Healthcare funded the development of the decision aids, but played no role in the conduct of the study, analysis, or interpretation of results.
Electronic supplementary material
Below is the link to the electronic supplementary material.
About this article
Cite this article
Coxeter, P.D., Del Mar, C.B. & Hoffmann, T.C. Preparing Parents to Make An Informed Choice About Antibiotic Use for Common Acute Respiratory Infections in Children: A Randomised Trial of Brief Decision Aids in a Hypothetical Scenario. Patient 10, 463–474 (2017). https://doi.org/10.1007/s40271-017-0223-2